Controlled Substance Contract  Associates in Internal Medicine Clinic NYPH

Patient Name___________________________________   MRN__________________________________________ Physician Name_________________________________

Controlled substances (opioid pain medication, benzodiazepine, sleep aides, amphetamine) are prescribed in an attempt to improve your physical and vocational function. To ensure the safety of these medication, it is important to follow the guidelines below:

1.      I understand that the medicine(s) prescribed for pain or anxiety management is to improve my quality of life and increase the amount of activity I can perform.

2.      I understand that it is likely that not all of my anxiety or pain will be relieved, and that the medicine(s) may be discontinued if it causes a deterioration in my function.

3.      In addition to the controlled medication(s), I agree to pursue other medication(s) and therapies suggested by my physician to improve my pain, anxiety, and function.

4.      I agree to attend regular appointments with my physician, and to follow up regularly with consultants and other types of therapy prescribed by my physician.

5.      I understand that controlled medications used over long-periods of time may cause dependence and if stopped abruptly may result in withdrawal symptoms.

6.      I understand that controlled medications may make me feel tired or mentally foggy. I agree to not drive or operate heavy machinery if I experience this type of side effect from medications. It is my responsibility to keep myself and others from harm.

7.      I agree to not misuse or abuse alcohol or illegal drugs while taking controlled medications.  I understand urine and blood screening test will be routinely performed in clinic.

8.      If I am active using illicit substances, I agree to attend addiction or mental health treatment as part of my treatment program.

9.      I agree to have only one primary physician write the plans for my narcotic pain or anxiety medications.  If other physicians sign my prescriptions, I understand that they will follow the plans written here by my primary physician.

10.  I agree to always take my medication as prescribed.  Any changes in dose must be made in consultation with my physician. I will bring my medication bottles with any remaining pills to every visit.

11.  I agree to fill my prescriptions at one pharmacy (name and number below).

12.  I am responsible for the safe keeping of my prescriptions, and my medications lasting the appropriate amount of time.  I understand that I may not receive additional medication ahead of scheduled time.

13.  For women: I understand these medications may be harmful to a fetus or a breast fed child, I will let my provider know if I am planning on becoming (or am) pregnant.

14.  If I do not follow the guidelines listed above, I understand that I will not receive further controlled medication from the clinic, and may be discharge from the clinic with adequate advance notice in order for me to obtain another health care provider.   

 

Patient Signature­­­­­­­­_____________________        Date:_________________

 

Primary Physician name:           

Primary Physician Signature:

Name of Pharmacy _________________________phone number

 

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Providers- Please document electronically the medication dose, quantity given, and prescription date for each refill.